Subcutaneous mastectomy with immediate reconstruction of the breasts, using the dermal mastopexy technique

Breast reconstruction after nipple-sparing mastectomy in the large and/or ptotic breast: A systematic review of indications, techniques, and outcomes

BACKGROUND

Surgeons remain reluctant to perform nipple-sparing mastectomy (NSM) in large breasts due to a higher risk of necrosis. We performed a systematic review of the literature to evaluate indications, techniques, and outcomes in immediate or delayed breast reconstructions in large and/or ptotic breasts.

METHODS

The following search terms were used for both titles and key words: [NSM AND ("breast ptosis" OR "ptotic breast" OR "large breast" OR "breast hypertrophy" OR "gigantomastia")]. All forms of breast reconstruction in large and/or ptotic breasts from 1990 through September 1st 2018 reporting indications, techniques, and outcomes were included.

RESULTS

Thirty-one studies met the inclusion criteria, yielding 1128 NSMs (709 immediate and 419 delayed) in 629 patients for analysis. The overall complication rate was 29.08%. The mastectomy flap necrosis rate was 12%, the partial nipple-areola complex (NAC) necrosis 11%, and the complete NAC rate 11%. The overall complication rate in one-stage versus delayed reconstructions was 37.52% versus 14.8%. The incidence of necrosis in one-stage versus delayed reconstructions was 5.36% versus 2.15% for partial, 5.08% versus 0.48% for complete NAC necrosis, and 4.8% versus 1.43% for skin flap necrosis.

CONCLUSIONS

The majority of studies being small and retrospective as well as the large variation in outcomes indicates that we lack consensus on the timing of reconstruction or ideal technique. A noticeable difference in skin flap and NAC necrosis, however, is seen in the favor of NAC-delayed procedures. Randomized controlled trials are mandatory to prove this difference significantly.

Nipple-Sparing Mastectomy and Prepectoral Implant/Acellular Dermal Matrix Wrap Reconstruction in Large Ptotic Breasts

Nipple-sparing mastectomy (NSM) with simultaneous prepectoral direct to implant reconstruction and acellular dermal matrix (ADM) is increasingly offered to patients opting for prophylactic or therapeutic mastectomies. The recent introduction of prepectoral implant/ADM in the armamentarium of breast reconstruction has proven to reduce pain and animation deformity. Despite this promising method, patients with macromastia and ptotic breasts remain a challenging group to treat. More often they would require secondary corrective procedures and can experience high failure rate and unsatisfactory outcomes. The authors present their experience in utilizing a bipedicled nipple-areola complex dermal flap through Wise pattern to achieve a successful NSM with prepectoral implant/ADM (Braxon) wrap (IBW) as a single stage in patients with large ptotic breasts. Patients seeking NSM with large ptotic breasts were included in the study in the period between 2016 and 2018. They were offered a single-stage Wise pattern NSM and immediate prepectoral IBW breast reconstruction. The technique and outcomes were recorded. Sixteen reconstructions were performed in 8 women with a median age of 32 years (range, 27-50 years) and a median body mass index of 32 kg/m² (range, 29-39 kg/m²). The resected breasts weight ranged from 750 to 1,600 g (median, 890 g). All procedures were completed successfully with no nipple-areola complex necrosis or failure experienced during the follow-up period (range, 3-24 months) with all patients reported excellent satisfaction. The authors' results demonstrate that this technique could be safely planned for NSM in large ptotic breasts with excellent durable outcomes.

Single Stage Nipple-Sparing Mastectomy and Reduction Mastopexy in the Ptotic Breast

PURPOSE

Given the proposed increased risk of nipple-areolar complex (NAC) necrosis, nipple-sparing mastectomy (NSM) is generally not recommended for patients with large or significantly ptotic breasts. NAC preserving strategies in this subgroup include staged or simultaneous NSM and reduction mastopexy. We present a novel approach towards simultaneous NSM and reduction mastopexy in patients with large, ptotic breasts.

METHODS

Literature pertaining to NSM for women with large, ptotic breasts was reviewed and a surgical approach was designed to allow for simultaneous NSM and reduction mastopexy in such patients.

RESULTS

Eight patients underwent bilateral NSM with simultaneous reduction mammaplasty and immediate reconstruction. The majority of breasts demonstrated advanced ptosis (69% grade III, 31% grade II) and the average breast volume excised was 760 grams. In those patients without a history of smoking, NAC necrosis rates were 0%. In those patients with a history of smoking, 83% of breasts experienced NAC necrosis (60% total, 40% partial). One hundred percent of patients who smoked experienced some degree of NAC necrosis. Among breasts with grade II versus grade III ptosis, NAC necrosis rates were roughly equal.

CONCLUSIONS

Historically, patients with large, ptotic breasts were excluded from NSM due to the proposed increased risk of NAC necrosis. This study demonstrates a safe approach towards NSM and reduction mastopexy using an inferior, wide-based, epithelialized pedicle. While all patients eventually achieved satisfactory results, there was an association between smoking and NAC necrosis. Smoking cessation is paramount to the operation's success.

Histological study on acute inflammatory reaction to polyurethane-coated silicone implants in rats

PURPOSE: Evaluating histologically the silicone peri-implant coated by polyurethane inflammation associated to the use of anti-microbial and bacterial contamination. METHODS: It was used 35 Wistar rats. The animals were divided in seven groups: I - Control; II - implant cavity contamination with10 bacteria/ml; III - implant cavity contamination with 10 bacteria/ml; IV - implant cavity contamination with 10 bacteria/ml; V - identical contamination to group II and implant immersions in anti-microbial solution; VI - identical contamination in group III and implant immersions in the anti-microbial solution; VII - identical contamination of group IV and implant immersions in anti-microbial solution. It was evaluated morphometrically the peri-implant capsules after 30 days of introduction. RESULTS: The factors with more discriminating power were the giants cells of a strange body and the mononuclear. There was no correlation between the bacterial concentrations and the histological alterations. CONCLUSION: 1) The histological standard of the inflammatory reaction around the silicone implant coated with polyurethan is chronic granulomatosis type of a strange body; 2) There isn´t correlation between concentration of Staphylococcus epidermidis and histological changes; 3) The use of anti-microbial solution decreased the mononuclear cell reactions, with the increase of giant cells in a strange body.

Subcutaneous mastectomy data: a final statistical analysis of 1500 patients

A statistical analysis of 1500 patients who underwent subcutaneous mastectomy is presented. Their data suggest that most patients who were treated by subcutaneous mastectomy had proliferative fibrocystic disease or macrocystic disease, among other high risk factors. The data also suggest that a thoroughly performed subcutaneous mastectomy is an effective means of providing prophylaxis in women who are at high risk for breast cancer. Conclusions were confirmed by many unsolicited comments of patients who underwent the procedure and were grateful to their doctors who performed it.

Breast modeling after subcutaneous mastectomy

The authors present their experience in two-team work in subcutaneous mastectomy, where the mastologists are responsible for the pathology of the breast and the plastic surgeon is responsible for the aesthetics and some of the complications arising from their aesthetical work. They make a minute study of existing operating techniques and present a personal contribution for breast modeling in cases of skin envelope reduction along with preservation of the neurovascular network of the nipple and the areola. They consider the secondary problems of this type of surgery and how they can be solved.

Adenomammectomy

Adenomammectomy is an operation for the removal of the glandular element of the female breast with the ultimate goal of reconstruction by prosthesis, by autogenous tissue, or by a combination of the two. Indications, technique, and complications are discussed.

Subcutaneous mastectomy with immediate reconstruction of the breast

The operation of subcutaneous mastectomy is evolving as an alternative to simple mastectomy for diseases of the breast parenchyma where preservation of the skin capsule is thought possible. Simple mastectomy is a mutilating procedure, cosmetically unacceptable to both patient and surgeon. The psychological implications of breast absence in women are now well known, and attempts to preserve the shape and volume of the breast must receive attention.

Body sculpturing

Significant improvements in body contour can be accomplished by surgical procedures having reliable, predictable results. Similar to the modern sculptor of inanimate art forms, plastic surgeons have utilized new materials and devised new techniques to achieve aesthetic improvement of the face, trunk, and extremities. The goals of the surgical sculptor are perhaps more challenging than those of the pure artistic sculptor, not only because they must result in improved appearance but also because the surgeon is limited at all times by considerations of regional anatomy, the availability of viable tissue materials, and the safety of his patient.